Dewa Nyoman Wirawan

Behavioral interventions for reduction of sexually transmitted disease/HIV transmission among female commercial sex workers and clients in Bali, Indonesia.

Objective:To describe and evaluate a behavioral intervention targeted to low-price female commercial sex workers (CSW) in large brothel complexes, their pimps, and their male clients. Design and methods:Fieldwork was conducted during 1994 in Bali, Indonesia. Intervention activities included an education program for CSW, pimp training, condom sales and distribution, and client media. Theoretical perspectives guiding the intervention were the Health Belief Model and social cognitive theory. Baseline and evaluation surveys were conducted to evaluate the intervention. Results:Both AIDS and sexually transmitted disease (STD) knowledge increased significantly over the intervention period. Condom use for vaginal sex with paid partners the day before the interview increased substantially in the two intervention areas: 18–75% and 29–62%. Condom use also increased in the control area, although the difference between baseline and evaluation measures was smaller. Multivariate analyses indicated that programmatic factors such as attendance at education sessions and reading the project brochure were related to condom use. Conclusions:Increasing community knowledge and awareness among low-price CSW, pimps, and clients regarding AIDS and STD using trained outreach workers is feasible and effective. In summary, this study has documented the effectiveness of a behavioral intervention for CSW and their clients.

The Bali STD/AIDS Study: evaluation of an intervention for sex workers.

Background Prostitution has been an important factor in the spread of HIV infection in Asia. Interventions need to be developed to reduce the risk of transmission of sexually transmitted infections in this area. Goals To educate female sex workers about sexually transmitted infections and assess the impact of the educational intervention. Study Design Brothel areas in Denpasar, Bali, Indonesia, were divided into areas of high and low program (interventional) effort. The intervention included educational sessions for sex workers, treatment of sex workers for sexually transmitted disease (STD), condom distribution, and printed information for clients of the sex workers. A high-effort area was one in which a more intensive educational intervention occurred. A clinic was available for STD treatment in both areas. Behavioral surveys and STD testing were used to evaluate the programs. Six hundred female sex workers participated in behavioral surveys and STD examinations every 6 months for four rounds of data collection. Each round, about half of the women were new to the study. A total of 1586 women participated in at least one evaluation round. Changes were evaluated in AIDS knowledge, STD knowledge, and condom use, as well as in the prevalence of Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, and Trichomonas vaginalis. Testing for HIV was conducted anonymously. Results Improvements were noted in the knowledge of sex workers about AIDS and STDs and in the reduction of some bacterial STDs. Women who remained in the study area for more than one round had increased knowledge of HIV infection/STDs and condom use and had reduced levels of syphilis, gonorrhea, and trichomonas infection (P < 0.01). The additional education received by women in the high-effort program area was associated with a reduction in the prevalence of syphilis. Prevalence of HIV remained low throughout the study. The high level of turnover of female sex workers contributed to the maintenance of significant levels of STDs in this population. Conclusions Developers of HIV/STD prevention programs for sex workers need to consider the mobility of the sex worker population. Interventions combining behavioral and medical approaches can contribute to prevention of these diseases.

Evaluation of a peer education programme for female sex workers in Bali, Indonesia

The objective of this paper is to evaluate a peer education programme for female sex workers in Bali, Indonesia. Sex workers participated in face-to-face interviews and STD exams in August-September 1998. In October 1998 one woman from each of 30 clusters was selected to be a peer educator and received a 2-day training on AIDS, STDs, condom use, and condom negotiation. After training, the peer educators were visited twice a week by field workers to answer questions and offer support. All sex workers received group education every 2 months. In January-February 1999, the sex workers again participated in face-to-face interviews and examinations. One month after peer education training, only 50% of the peer educators were still working in the clusters where they were trained. To evaluate the impact of the peer educators, sex workers in clusters where a peer educator continued to work were compared with sex workers in clusters where women did not continue to work (n = 189). In clusters where women continued to work, there were higher levels of AIDS knowledge (P < 0.05), STD knowledge (P < 0.05) and condom use (82 vs 73%, P = 0.15). The prevalence of Neisseria gonorrhoeae infection was also lower in clusters with a peer educator (39% vs 55%, P = 0.05) than in clusters without a peer educator.

The Bali STD/AIDS study: association between vaginal hygiene practices and STDs among sex workers.

Objectives: To assess the association between genital cleansing practices and the prevalence of sexually transmitted diseases and of sexual health knowledge among female sex workers in Bali, Indonesia. Methods: Low priced commercial sex workers (CSWs) participated in the Bali STD/AIDS Study, a 3 year educational project evaluating the effect of education on the subsequent use of condoms and the prevalence of STDs and AIDS. Structured interviews, genital evaluation, laboratory evaluation for STDs, and treatment were performed. Vaginal cleansing characteristics including frequency, type, and reasons for use, were evaluated. Associations between these characteristics and the presence of bacterial and viral genital infections were assessed. Results: Of 625 female sex workers evaluated between May and July 1998, 99.1% used substances, such as soap and toothpaste, to clean the vagina at least daily, with 69.3% performing this after each intercourse. The women using such cleansers after each client did not differ from those using them once or less daily in education, AIDS and condom use knowledge, time working as a CSW, or number of clients in the previous day. However, they were younger than those using vaginal cleansers daily or less, and reported lower condom usage in the past week. Several genital symptoms, such as discoloured discharge and odour, were reported less by women with the highest frequency of vaginal cleanser use. Prevalence of genital infections in this population of women was substantial, with bacterial infections more prevalent than viral infections. Infections were not associated with the type of cleanser used, using a genital cleanser on the day of examination, or using a cleanser after each client versus daily or less, except for candida colonisation, which was more prevalent in women cleansing after each client (OR=1.87, 95% CI 1.21, 2.90). However, symptomatic candida vulvovaginitis (positive culture plus presence of symptoms) was not associated with the prevalence of genital cleansing. Women using genital cleansing in part for “infection avoidance” (39.7%) were more likely to have heard of STDs and AIDS, but were less knowledgeable about these infections, compared with women not citing this reason for genital cleansing. Conclusion: Commercial sex workers in low priced brothels in Bali have a high rate of genital infections, with lower rates of viral compared with bacterial infections. Genital cleansers, on a daily or after each intercourse schedule, are used routinely. Although genital cleansing after each intercourse was associated with fewer genital symptoms, the prevalence of STDs did not differ significantly based on this frequency, and the womens knowledge of STDs and AIDS was less than that of women cleansing less often. The effect of genital cleansing in general on STD and AIDS prevalence could not be assessed in this population owing to the lack of a non-cleansing cohort. Further study to elucidate the effect of vaginal cleansing practices on STD prevalence and resistance is needed.

AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia.

ObjectivesTo describe the AIDS/sexually transmitted diseases (STD) knowledge and risk behaviors, and to determine factors related to condom use among male commercial sex workers (CSW) and male tourist clients in Bali, Indonesia. DesignIndividual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali. MethodsSurvey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking. ResultsMost of the male CSW had heard about AIDS and other STD, although some misconceptions about transmission and risks of different sexual practices remained. Both oral and anal intercourse with tourists were common and condom use was far from consistent. Factors related to condom use for anal intercourse with tourist clients were condom beliefs, self efficacy, susceptibility to STD infection, and STD knowledge. Tourist clients were mainly from Australia and Europe and many had paid for sex in other parts of Indonesia as well as in high prevalence countries. Knowledge of AIDS/STD was very good among the tourists and previous experience with STD was common. Factors related to condom use with male CSW were condom beliefs and self efficacy. ConclusionThere is a very active and mobile group of male CSW and tourist clients present in Bali. Interventions with these men are needed due to the low level of knowledge about AIDS among CSW, their experience with STD and STD symptoms, and their level of risky sexual behavior.

AIDS knowledge, risk behaviors, and condom use among four groups of female sex workers in Bali, Indonesia.

The objectives of this study were to discover the AIDS knowledge, risk behaviors, and condom use of four groups of female professional sex workers (n = 614). Personal interviews were conducted with women working in low-price brothels, mid-price and high-price houses, and tourist areas. Only 51% of women in the low-price brothels had heard of AIDs, although most of the women in the other groups had heard of it. Knowledge of transmission and symptoms was weak in all groups, and most women were unaware of asymptomatic transmission. Most women felt safe from HIV due to ineffective strategies such as taking medications or client selection practices. Condom use with clients varied widely by group. Women in the low-price brothels reported the lowest levels of use (19% of encounters in the previous week), with women from the mid- and high-price groups reporting higher levels (68% mid-price; 71% high-price). Women working in the tourist areas reported the highest levels of use (90%). Interventions for each group need to reflect these differences in knowledge as well as the contexts of their work; important contextual factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

Fluoroquinolone-resistant Neisseria gonorrhoeae in Bali, Indonesia: 2004.

Objectives: In the mid-1990s, fluoroquinolones were introduced in Indonesia for the management of gonorrhea and are now part of the national recommended treatment guidelines. We recently documented introduction of ciprofloxacin-resistant Neisseria gonorrhoeae strains in female sex workers (FSWs) in Timika, Indonesia, 5 years after treating gonococcal cervicitis with ciprofloxacin and periodically monitoring antimicrobial susceptibility of isolates. To assess the importance of this observation, we determined antimicrobial susceptibilities and strain types of N. gonorrhoeae isolates from FSWs seen in a sexually transmitted infection (STI) clinic in Denpasar, Bali, Indonesia. Goal: The goal of this study was to determine antimicrobial susceptibilities and strain types among N. gonorrhoeae isolated from FSWs in Denpasar, Bali. Study Design: FSWs in Denpasar were screened for N. gonorrhoeae by standard culture. Endocervical isolates were frozen in Microbank tubes and sent to the University of California at San Francisco on dry ice. Antimicrobial susceptibility testing using a Clinical Laboratory Standards Institute-recommended agar dilution method was performed at the Centers for Disease Control and Prevention. Isolates were characterized by &bgr;-lactamase production, antimicrobial resistance phenotypes, and auxotype/serovar class. Results: One hundred forty-seven N. gonorrhoeae isolates were characterized. All isolates were highly resistant to tetracycline (minimum inhibitory concentration, ≥16.0 &mgr;g/mL): 117 (79.1%) were &bgr;-lactamase-positive (PP-TR), 3 (2.0%) exhibited chromosomally mediated resistance to penicillin (PenR-TRNG), and 27 (18.2%) were susceptible to penicillin (TRNG). All isolates were susceptible to ceftriaxone, cefixime, and spectinomycin; lack of interpretive criteria do not allow interpretation of susceptibilities of cefoxitin, cefpodoxime, or azithromycin. Fifty-nine (40.1%) isolates were ciprofloxacin-resistant; 35 (59.3%) of the ciprofloxacin-resistant isolates exhibited high-level resistance to ciprofloxacin (Cip-HLR; minimum inhibitory concentration, ≥4.0 &mgr;g/mL of ciprofloxacin). Three (2.0%) isolates were intermediate to ciprofloxacin. Twenty-two strain types were identified among these isolates; small clusters were identified with 3 strain types. Conclusions: N. gonorrhoeae isolates from FSWs in Denpasar were resistant to penicillin and tetracycline; 40.1% of the isolates were fluoroquinolone-resistant. With gonorrhea prevalence of 35% at this clinic (by nucleic acid amplified tests), ongoing surveillance for antimicrobial resistance will be needed to appropriately choose treatment for infections caused by these resistant organisms.

The Bali STD/AIDS study: human papillomavirus infection among female sex workers.

Female sex workers in low priced brothel areas in Denpasar, Bali, Indonesia participated in an intervention study designed to promote condom use and sexually transmitted disease (STD)/AIDS prevention. The intervention provided educational sessions for sex workers, STD treatment for sex workers, condom distribution, and media for clients. The brothel areas were divided into high and low areas for programme effort. The high effort areas received a more intensive behavioural intervention than the low effort areas. A clinic was available for STD treatment in both areas. Behavioural surveys and STD testing were used to evaluate the programmes. About 600 were evaluated for several STDs and completed personal interviews at enrolment and at six-month intervals during the 18-month study. About 50% of women were new to the study at each round. Human papillomavirus (HPV) testing of cervical swabbed specimens, using polymerase chain reaction methodology, was performed at the beginning of the study and 18 months later. Human papillomavirus infection was initially high in these women (38.3%) and declined to 29.7% after 18 months (P <0.01). The prevalence of HPV infection declined with age (P <0.01). HPV infection was associated with a number of STD symptoms that were reported in personal interviews. These associations were stronger in the first time period. Infection with Neisseria gonorrhoeae was associated with HPV infection at baseline (P =0.03). HPV infection declined in the study area with the more intensive educational programme (P <0.01). The prevalence of HPV infection declined over time and was associated with study area and age of woman.

Condom use among brothel-based sex workers and clients in Bali, Indonesia

BACKGROUND The objective of this paper is to describe the situation among Indonesian sex workers and clients in Bali, Indonesia, through a series of studies conducted during the 1990s. METHODS Five surveys of sex workers and clients were conducted from 1992 through to 1999. RESULTS The proportion of female sex workers who have heard about AIDS and condom use has increased tremendously in this area. In 1992-93, 51% of women reported ever hearing of AIDS and this had increased to 97% by 1999 (P < 0.01). Reported condom use with clients increased from 19% in 1992-93 to 78% in 1999 (P < 0.01). However, condom use is still far from 100% and perceived susceptibility towards HIV infection among female sex workers and their male clients remains low. Ineffective preventive strategies such as medication use remain common. HIV infection was very low in this population, although the prevalence of other sexually transmitted infections such as gonorrhea and chlamydia was very high. CONCLUSIONS Educational interventions have been conducted with the sex workers, but the main source of education for clients has been through the media. Future programs need to develop more focused efforts to reach clients. These interventions may include worksite interventions, mass media campaigns, youth programs or other models.

Mortality among people living with HIV on antiretroviral treatment in Bali, Indonesia: incidence and predictors:

Indonesia has the third highest number of people living with HIV/AIDS (PLWH) and the greatest increase in proportion of AIDS-related mortality in the Asia Pacific region between 2005 and 2013. Longitudinal mortality data among PLWH in Indonesia are limited. We conducted a retrospective cohort study from medical records of antiretroviral treatment (ART) recipients attending Badung General Hospital (BGH) and Bali Medica Clinic (BMC) between 2006 and 2014. We explored incidence of mortality by Kaplan–Meier analysis and identified predictors using a Cox proportional hazard model. In total, 575 patients were included in the analysis; the majority were male. The overall mortality rate was 10% per year. Multivariate analysis suggested that being male (adjusted hazard ratio [aHR]: 2.74; 95% confidence interval [CI]: 1.34–5.59), having a lower education (aHR: 2.17; 95%CI: 1.31–3.61), having heterosexual (aHR: 7.40; 95% CI: 2.61–21.00) or injecting drug use (aHR: 13.20; 95% CI: 3.17–55.00) as the likely transmission risk category, starting treatment with low CD4 cell counts (aHR: 3.18; 95% CI: 1.16–8.69), and not having a treatment supervisor (aHR: 4.02; 95% CI: 2.44–6.65) were independent predictors of mortality. The mortality was high, particularly in the first three months after initiating ART. These findings highlight the need to encourage HIV testing and early diagnosis and prompt treatment. Applying aspects of BMCs targeted HIV services model in more generalised services such as BGH may be beneficial. Providing adherence support as part of ART services is key to promoting adherence to ART.